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Kick Ass Respiratory Exam > Mechanical Ventilation > Flashcards

Mechanical Ventilation Flashcards

1
Q

What type of trigger variable may be more responsive to a patient breathing pattern

A

Flow triggered

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2
Q

What is the advantage and disadvantages of the volume cycled variable in mechanical ventilation?

A

Advantage: minute volume will remain constant to provide stable blood gases

Disadvantage: as lung compliance or resistance, worsen, PIP, and plateau pressure increase, which may cause barotrauma, or volutrauma.

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3
Q

What is the normal cycling variable in pressure support ventilation?

A

Flow cycling

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4
Q

What are the alarm settings for high-pressure, minimum exhaled volume, XL, low pressure, and oxygen in mechanical ventilation

A

-High pressure set 10 cm H2O above peak airway pressure
-Minimum exhaled volume set 100 mL below exhaled tidal volume.
-Low pressure set 10 cm below peak airway pressure
-Oxygen set 5% above and below FiO2 setting

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5
Q

What 3 devices, verify accuracy for volume, pressure, and flow

A

Volume-barometer,

Pressure-mercury or water manometer

Flow-Rotamater

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6
Q

What are the indications for continuous, mechanical ventilation?

A

Apnea
Acute ventilatory failure
Impending ventilatory failure -trend of rising, PCO2 and or decreasing Vt, Vc and MIP
Oxygenation

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7
Q

What bedside ventilator parameters can indicate mechanical ventilation is necessary

A

Vital capacity < 10 mL/kg
MIP <20 cm H2O
RR <8 or >20
Tidal volume < 5 mL/kg
VE >10 L/min

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8
Q

What physiological assessment or calculations indicate mechanical ventilation is necessary

A

Deadspace greater than 60%
Shunt greater than 20%
Static compliance < 25 mL/cn H2O
A-a DO2 >300 torr

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9
Q

What are the initial settings for mechanical ventilation?

A

Vt= 5-10 mL/kg of ideal body weight
Pressure (PC)= use plateau from VC or <35 cm H2O
RR=10-20
FiO2=40-60, set at lvl prior to ventilation
PEEP=2-6.. set at lvl prior to ventilation

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10
Q

What is the formula to determine ideal bodyweight weight?

A

50 kg + (2 x inches over/under 5 ft.

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11
Q

Increasing what ventilator parameter best increases alveolar ventilation

A

Tidal volume

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12
Q

How much dead space is in an inch of flex tubing

A

10 mL

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13
Q

The sum of anatomic and alveolar deadspace is called what

A

Physiologic deadspace

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14
Q

What is the frictional force that must be overcome during breathing called and what is the normal range?

A

 Airway resistance

0.6-2.4 cm H2O/L/sec. As high as 6 in intubated patients

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15
Q

What are two common causes and treatments for increased peak pressures?

A

Secretions in airway – suction

Broncospasm – broncodilators

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16
Q

What are the causes and suggested treatments of decreasing lung compliance (Cl)?

A

-Atelectasis
-Pulmonary edema
-ARDS
-Pneumonia

Increase PEEP and treat underlying cause

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17
Q

What ventilator control has the greatest influence on mean airway pressure (Paw)?

A

PEEP

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18
Q

What is the typical mean airway pressure in obstructive disease?

A

10-20 cm H2O

Normal: 5-10
ARDS: 15-30

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19
Q

Mean airway pressure (PAW) has the greatest impact on what life function

A

Oxygenation

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20
Q

How can you measure the work of breathing?

A

Change and pressure multiplied by the change in volume

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21
Q

What happens when work of breathing increases and respiratory muscles tire

A

Tidal volume decreases and respiratory rate increases

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22
Q

What are indications to switch a patient to SIMV

A

-Tachypneic patients to avoid hyperventilation
-To lower mean airway pressures.
-Used with peep to reduce barotrauma

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23
Q

Inverse ratio ventilation (IRV) improves, oxygenation and gas exchange and decreases PIP and PEEP levels. What patient criteria would indicate its use?

A

-patients requiring FiO2 over 60% and peeps greater than 15 cm H2O.
-PIP’s greater than 50 cm H2O
-Low PaO2 with decreased compliance

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24
Q

What ventilation mode is a form of spontaneous breathing at a positive pressure level, similar to CPAP, That occasionally releases the baseline pressure resulting in lower PIPs and mean airway pressure?

A

Airway pressure release ventilation (APRV)

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25
Q

What ventilator mode improves oxygenation using lower mean airway pressures

A

Airway pressure release ventilation (APRV)

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26
Q

What ventilator mode is a form of ventilation that keeps pressure at the lowest level by providing automatic breath to breath, pressure regulation while providing a preset volume

A

Pressure regulated volume control (PRVC)

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27
Q

What mode of ventilation has the characteristics or where pressure, volume and flow are proportional to the patient’s spontaneous efforts

A

Proportional assist, ventilation (PAV, or PAV+)

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28
Q

How would you initially determine settings for pressure support ventilation?

A

By calculating the patient’s airway resistance (PIP-Plateau).

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29
Q

What is the goal of pressure support ventilation

A

Overcome the resistance of the ventilator circuit and endotracheal tube during spontaneous ventilation

30
Q

What mode of ventilation is indicated with PIP’s > 50 cm H2O or air leak syndromes to improve oxygenation Impatience with severe lung injury

A

High frequency oscillatory ventilation (HFOV)

31
Q

What are the typical Hertz settings in high frequency oscillatory ventilation (HFOV)

A

3 to 15 Hz

1 Hz equals 60 cycles per minute

5 Hz equals 300 breaths per minute

32
Q

In high frequency oscillatory ventilation, HFOV, what is the characteristics and goals of the ventilator parameters?

A

Very high, respiratory rates result in low alveolar pressure changes
Title volumes are very low (< 5 mL)

33
Q

What are the two ways you would decrease PaCO2 in HFOV?

A

Primary-increase amplitude

Secondary-Decrease Hz frequency

34
Q

When you wish to normalize a high PCO2 during mechanical violation, you should follow what order of?

A
  1. remove mechanical, dead space if possible
  2. Increase the tidal volume or PIP
  3. Increase the respiratory rate.
35
Q

When you wish to normalize a low PaCO2, you should follow what order of steps

A
  1. evaluate the cause (hypoxemia, pain, fever and anxiety)
  2. decrease the respiratory rate
  3. Decrease the tidal volume or PIP.
36
Q

When you wish to increase a low PaO2, you should follow what order of steps

A
  1. Increase FiO2 by 5 to 10% up to 60%.
  2. increase peep levels by 2 to 5 cm H2O until acceptable oxygenation achieved or unacceptable side effects occur
37
Q

What are potential side effects of high levels of peep?

A

Decrease compliance
Decreased cardiac function
Barotrauma
Increased C(a-v)O2

38
Q

What is the order of steps to decrease a high PO2?

A
  1. Decrease to less than .60
  2. Decrease PEEP
39
Q

What are the ARDS net protocols?

A

1.Initial title of 8 mL/kg IBW and then reduce to 6 mL
2. Maintain plateau pressures < 30 cm of H2O
3. Consider permissive hypercapnia and subsequent respiratory acidosis.

40
Q

What is the goal of a recruitment maneuver (RM)?

A

Sustained increase in pressures in along with the goal of opening as many collapsed lung units as possible

41
Q

Please describe the most common recruitment maneuver (RM) for both peep and CPAP

A

Peep: increase peep to 40 cm of H2O for 40 seconds
CPAP: increase CPAP levels to 20 cm H2O for 20 seconds

42
Q

If SPO2 rises and then falls, how many times can you consider repeating a recruitment maneuver?

A

Once

43
Q

When should prone positioning be considered?

A

When FiO2 levels > .60 and PEEP levels are greater than 12 cm of H2O or when recruitment maneuvers have failed

44
Q

Proning is successful in what percent of patient patients with ARDS and should improve PO2 within 30 minutes

A

75%

45
Q

When successful, prone positioning, has what impact on PaO2, PaCO2, and shunt?

A

PaO2-increase by 10 to 50 torr
PaCO2-May decrease
Shunt-decreased by 12 to 25%

46
Q

In normal loop graphics, what characteristic identifies an assisted breath?

A

A fish tail

47
Q

What are high and low inflection points used for?

A

High – best volume

Low – best peep

48
Q

What type of loop best identifies airway resistance, and what shape is characteristic of high airway resistance

A

A flow volume loop

Flattened ball

49
Q

What does a broken loop in a ventilator graphic indicate?

A

An air leak

50
Q

How can you identify water condensation in a flow volume loop?

A

Scalloped pattern

51
Q

What type of ventilator graphic helps determine best peep, and volume?

A

A volume Pressure loop

52
Q

What type of graphic is used to identify auto peep and how?

A

Scalar graphics.
The expiratory flow does not return to baseline before the next breath starts.

53
Q

What are adverse effects of auto peep?

A

-Decreased cardiac output.
-Decreased blood pressure
-Increased intracranial pressure
-Over distention of alveoli resulting in barotrauma
-Difficulty triggering the ventilator

54
Q

What are some reasons for an auto trigger in mechanical ventilation?

A

-Bounding pulse or cardiac movement
-Leaks in circuit or airway.
-Inappropriate trigger setting
-Condensation in circuit

55
Q

What type of medication is used to decrease anxiety and promote relaxation and what are some names?

A

Sedatives, the ams and pams
Diazepam

56
Q

What type of medication can reduce a patient’s ability to perceive sensation and what are some drug names?

A

Anesthetic
Propofol
ketamine
Etomidate

57
Q

What type of medication reduces a patient sensation of Pain and what are a few common drugs

A

Analgesics & opioids
Morphine
Codeine
Fentanyl
Oxycodone, and all other dones

58
Q

What are neuromuscular blocking agents used for?

A

Cause paralysis of skeletal muscle

Pancuronium and all onium meds

59
Q

What is the best method to evaluate if a patient is ready for weaning

A

A spontaneous breathing trial with CPAP and with or without pressure support

60
Q

What is the minimum and maximum time for a spontaneous breathing trial?

A

30 minutes up to 2 hours

61
Q

What is the heart rate and respiratory rate criteria for termination of a spontaneous breathing trial. What are some other indicators?

A

Respiratory rate > 35 BPM for over five minutes
Heart rate greater than 130 or 20% over baseline
Blood pressure instability, Systolic blood pressure greater than 180 or less than 90
Cardiac arrhythmias
Oxygen saturation less than 90% or decreased 4% from baseline
pH less than 7.30

62
Q

How long should you wait to repeat a spontaneous breathing trial (SBT)?

A

 24 hours

63
Q

What types of drugs should be discontinued for a SBT?

A

Narcotics neuromuscular blocking agents

Anesthetics

64
Q

How long after a ventilator wean has been initiated should an ABG be run?

A

20-30 minutes

65
Q

Atelectasis can be common following extubation. What should be recommended to prevent it?

A

SMI or IPPB

66
Q

After how long of failed weaning attempts is a patient considered ventilator dependent

A

Three months

67
Q

What are the indications for noninvasive positive pressure ventilation

A

Acute exacerbation of chronic respiratory failure (COPD)
Congestive heart failure or pulmonary edema.

Severe dyspnea with a do not intubate order

68
Q

What are the advantages of NPPV?

A

Avoids ventilator associated pneumonia

Avoids complications of an artificial airway

Avoids complications of mechanical ventilation

69
Q

What are the recommended initial settings for NPPV?

A

IPAP: 8 to 12 cm H2O

EPAP: 4 to 6 cm of H2O

70
Q

How do you calculate rapid shallow breathing index and what’s acceptable

A

RR / VT in L (ie. 0.4)

Less than 100

Kick Ass Respiratory Exam (9 decks)

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